Stronger health systems. Greater health impact. The Accredited Drug Dispensing Outlets in Tanzania Community Providers of Medicines for Child Health Eliphace Mkumbo and Dr. Suleiman Kimatta Management Sciences for Health 1
ADDO Initiative Background • MSH and MOHSW-Tanzania carried out a pharmaceutical sector assessment in 2001 with funding from the Gates Foundation • Major access gaps identified — Quality of drugs and services Registered pharmacies only in major urban areas High stock-outs rates for essential medicines at primary health facilities Essential prescription medicines illegally sold by duka la dawa baridi • Solution = accredited drug dispensing outlet program (ADDO) Management Sciences for Health 2
ADDO Program Objectives • Increase the availability of essential medicines to the rural communities where majority of the people live • Improve the quality of medicines that people buy from drug sellers • Improve the quality of dispensing services from both technical and consumer perspectives • Make essential medicines and pharmaceutical services available and affordable* to people in the rural and peri-urban areas. *Assuring that the accreditation process did not dramatically increase drug prices in shops. Management Sciences for Health 3
ADDO Strategy for Change • National and local authorities, professional associations Gain broad-based support • Participatory approach to project design and from all stakeholders implementation Develop requirements and • Create accreditation standards build stewardship and • Decentralized inspection strategy; central oversight governance capacity • Products in stock registered by TFDA; local suppliers • Business skills of owners • Case management and communication skills of dispensers Build private sector capacity • Mentoring and supervision • Record keeping • Ability to sell expanded range of medicines legally Provide incentives • Loans • Mobile technology applications (e.g., mobile money) Management Sciences for Health 4
Types of Medicines ADDOs Sell • Antibiotics (including • Laxative pediatric formulations of • Cardiovascular amoxicillin for • Diuretic pneumonia) • Fluids/ electrolytes • ORS/zinc • Local anesthetic • Antimalarials • Oral contraceptives • Antifungals • Minerals/vitamins • Anti-inflammatory/ • Anti-epileptics analgesics • Antispasmodics • Oxytocic • Anti-asthma • Antihistamines Management Sciences for Health 5
ADDO Program Status As of November 2015 Regions scaled up 25 (100%) Shops accredited >8,000 (ADDOs) Shops in accreditation <2,000 process Trained dispensers >19,000 >500 Trained district inspectors Management Sciences for Health 6
Community Source of Medicines • First choice for 45+% of medicine purchases • Over 9,000 drug shops compared to nearly 800 registered pharmacies in Tanzania • Close proximity — 95% of population within 5 km of a drug shop • Perception of being more personal; flexible payment methods • Public health facilities often farther away; essential medicines often out-of-stock Management Sciences for Health 7
ADDOs as an Integrated Platform for Community- Based Public Health Interventions Child health/IMCI/ Services to Access to ACTs Source of Early TB case HIV/AIDS improve access to members of and insecticide- family planning detection and information amoxicillin & National Health treated nets products referral dissemination zinc/ORS co-pack Insurance Fund Management Sciences for Health 8
Assuring Quality Products and Services (1) • ADDOs must stock products registered by Tanzania Food and Drugs Authority • ADDOs buy products from approved local wholesalers • Drug quality assurance testing on 243 samples ADDOs (203) and pharmacies (40) in four regions showed — 227/243 samples met quality standards (93.4%) • Pharmacy Council of Tanzania oversees ADDO operations — Official accreditation — inspection to assure that shops meet standards Qualifications of dispensers Premises meet quality standards Re-accreditation system (mechanism not yet functional) Management Sciences for Health 9
Assuring Quality Products and Services (2) • ADDO training covers supply chain management components Dispensing environment (e.g., staff hygiene, clean storage space) Stock arrangement on shelves with proper labeling Stock rotation (FIFO and expiry monitoring) Storage conditions (e.g., security, temperature, moisture, light, pests) Maintaining stock cards and sales ledgers to track inventory • ADDO inspections performed quarterly by local inspectors; 3,262 district and ward inspectors have been trained • Promising work with ADDO associations providing peer-peer supervision • New mobile technology to report on service indicators, including product availability Management Sciences for Health 10
UNICEF Pilot Project in Three Regions • UNICEF requested MSH to help improve community access to amoxicillin DTs and ORS/zinc co-packs for childhood pneumonia and diarrhea through ADDOs in three pilot regions • Amoxicillin DT and ORS/zinc co-packs had previously not been available in the private sector • Activities include — Orientation of district health office, ADDO, and supplier personnel on how to supply/dispense new formulations Supervision of ADDO dispensers and owners in related practices Monitoring and reporting on availability of new products using mobile technology Management Sciences for Health 11
CHW-ADDO-Health Facility Linkage • Tanzania’s community health workers (CHWs) are not allowed to dispense any medicines at all; they can only refer to a health facility • ADDOs refer severely sick patients to health facilities and refer patients who require medicines not available at ADDOs • A formal link between ADDOs and CHWs does not exist • MSH project in Kibaha linked ADDOs with CHWs and health facilities to improve community- based access to medicines Management Sciences for Health 12
Strengthen Linkage at Community Level Malaria Family Planning Pneumonia Referrals Community Health Workers Health Facilities ADDOs Management Sciences for Health 13
Expected Outcomes of Linkage • Show CHW/ADDO/health facility willingness to collaborate • Increase efficiencies and access; for example, CHWs refer pneumonia cases to ADDO for treatment rather than distant health facility • Enhance CHW, ADDO, and health facility workers’ knowledge in reproductive, maternal, newborn, and child health • Improve stock of essential RMNCH commodities and medicines in ADDOs and health facilities Management Sciences for Health 14
RMNCH commodity availability: ADDOs Proportion of ADDOs with essential commodities: June and July 2015 (n = 24) 100 100 96 95 95 95 96 92 90 90 90 88 88 90 84 81 80 80 80 70 64 60 Percent 50 40 30 20 10 0 0 0 ORS Zinc Amoxycillin ACT SP Folic Acid Quinine Female Male The Pills Condom Condom 1st supervision 2nd supervision Management Sciences for Health 15
Conclusions • ADDOs are an important provider of appropriate treatment for common childhood illnesses at community level • Assuring the availability and quality of medicines is crucial and is covered in ADDO training/supervision; availability of RMNCH commodities in ADDOs is good; 2013 data showed excellent product quality from ADDO samples • Further exploration of how CHW-ADDO-health facility linkages can strengthen referrals and increase timely appropriate treatment Management Sciences for Health 16
Stronger health systems. Greater health impact. Saving lives and improving the health of the world’s poorest and most vulnerable people by closing the gap between knowledge and action in public health. Management Sciences for Health 17
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